MEDICARE: NIKI ROSE JACKSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	T4184	TX

General Provider Information

NPI Number	:	1083140891
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NIKI ROSE JACKSON MD

Provider Business Mailing Address
First Line	:	3032 MARINA BAY DR STE 200
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-4668
Country	:	US
Telephone Number	:	832-604-6534
Fax Number	:	832-604-6531

Provider Business Practice Location Address
First Line	:	3032 MARINA BAY DR STE 200
Second Line	:
City	:	LEAGUE CITY
State	:	TX
Zip	:	77573-4668
Country	:	US
Telephone Number	:	832-604-6534
Fax Number	:	832-604-6531

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/11/2017
Last Update Date	:	12/11/2024

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